1. Field of the Invention
The present invention relates in general to the field of electronics, and more specifically to a system and method for automated learning and medical data processing.
2. Description of the Related Art
Medical records often include patient information and a history of patient examinations, orders, and recommended treatment plans. Medical treatment facilities, such as hospitals, clinics, and physician offices, utilize the medical records for a variety of purposes. Such purposes include providing historical reference data that is useful for patient follow-up and subsequent examinations and treatment. Additionally, the medical records provide a basis for invoicing and compensation for medical services rendered. Additionally, medical records can provide data useful in measuring the historical quality of a particular treatment facility and/or treating clinician. The term “clinician” as used herein is a generic term representing any health care provider including physicians, physician assistants, nurses, medical lap technicians, psychologists, and physical therapists.
FIG. 1A depicts a medical record storage system and process 100. The medical record storage system and process 100 stores medical records 105 in a database of a medical record storage server 103 for subsequent access and processing. Clinicians examine a patient and record medical history data regarding the patient, the examination, and a recommended treatment. The medical data is recorded by personnel 102, submitted to the medical record storage server 103, and stored as electronic medical records 105. The method of electronic recordation is generally transcription of hand-written notes 104, direct entry 106 into a computer using, for example, a keyboard or voice recognition technology, or scanned 108. The medical records 105 are stored as images, such as portable document files (PDF) or other image format types. Government regulations can encourage the creation of electronic medical records by providing financial incentives for the creation of electronic medical records or penalties for failing to create electronic medical records.
The medical records 105 are generally coded in accordance with medical classifications in accordance with a standard set of medical record codes such as the International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD). The ICD is a medical classification that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. Under this system, every health condition can be assigned to a unique category and given a code, up to six characters long. Such categories can include a set of similar diseases. The ICD is published by the World Health Organization (WHO) and used worldwide for morbidity and mortality statistics, reimbursement systems, and automated decision support in medicine. The ICD coding system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics.
In addition to ICD, additional medical record codes include the Current Procedural Terminology (CPT) code set, which is maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
To code the medical records 105 in accordance with the current ICD, human coders utilize a coding system 112 to access the medical records in the medical record storage server 103. The coding system 112 inserts the ICD codes into the medical records 105 and sends an invoice 114 to an appropriate entity such as an insurance company, the government, or a patient. Additionally, the medical records 105 can be examined by a human operator utilizing a core measures system 116, which abstracts data to be reported in a medical quality report 118.
FIG. 1B depicts another embodiment of a medical record storage system and process 150. To facilitate electronic storage, search ability, and subsequent processing, electronic medical record (EMR) system and process 150 forces clinicians to enter medical data into a template 152. The template 152 represents a standard data structure for subsequent processing. Clinicians are generally trained to document medical data in accordance with a “SOAP” note, where “SOAP” stands for subjective, objective, assessment, and plan. The manner in which clinicians are trained during their medical education to document medical records does not easily correlate to a structured template format. Consequently, clinicians may, for example, utilize a comments field in the template 110 to enter medical data, and the template may not be fully populated. Once populated with data from the clinician, the templates are stored as electronic medical records 154. The electronic medical record database 156 attempts to generate invoices 158 and reports 160 based on the electronic medical records 154. The accuracy and completeness of the invoices 158 and reports 160 depends on the accuracy and completeness of the electronic medical records 154. There is no guarantee of the accuracy and completeness of the electronic medical records 154.
Clinicians often utilize paper forms or prepared electronic templates to enter data for recordation in a medical record. A clinician may enter information that is objectively ambiguous or lacks sufficient detail for proper post-processing use. This can be the result of, for example, a clinician's idiosyncrasies, lack of granularity, or colloquialisms in the template. For example, a patient may present with mid-back pain. However, if the clinician records the encounter in a template containing only standardized entries for upper and lower back pain, the clinician may choose the best option available or enter “mid-back pain” in a comments field. The idiosyncrasies manifest in any of a variety of manners. For example, a clinician may enter the term “PT”, which may mean a “patient” or mean “physical therapy”. The template has no way of interpreting the meaning, and, thus, a human interprets the meaning manually.
After the medical records 105 and 154 are created, government regulations prevent subsequent editing of the medical records 105. Consequently, the medical records 105 and 154 may be inaccurate and, thus, result in inaccurate invoicing and reporting.